Targets can be as hindering as they are helpful – continued reform is much more important

The Amanjit Jhund NHS Column

This weekend has seen battle lines being drawn with the Conservatives over the issue of waiting times and targets. Andy Burnham has announced that he wishes to enshrine many of the Labour party’s pledges on waiting times in the statute books in effect to “Tory proof” the NHS. The primary beneficiary of this policy will be the 18 week target on treatment.

As the Conservatives have committed themselves to abolishing Labour’s targets developed over the past 12 years, there is a genuine fear that this will only result in the return of ever increasing waiting times in the long term, and this is seen as the only way of preventing that in the event of a Conservative victory. The Tories have hit back with Andrew Lansley claiming that the proposals are “more to do with electioneering than improving the NHS” and I’m inclined to agree with him.

One of the innovations of the past 12 years that I am most proud of is the 2 week cancer wait; I believe it has increased the standard of care for many people across the country. Combined with the vast reduction in waiting times seen since the last Conservative government the improvements represent several of the features of the NHS that every Labour party supporter and activist should be proud of.

Where used in an intelligent manner targets can have a transformative effect upon the patient experience and I do vehemently disagree with the Conservative proposals to scrap all targets. We shouldn’t get carried away, though – not every one of our targets has been an unqualified success: the 4 hour wait in A&E has been widely barracked by both medical professionals and the professional bodies such as the British Medical Association (BMA). The purpose of these targets has been to increase the standard of patient care; however, some of these targets have had the opposite effect.

My greatest worry, then, is that we will see not only some of the beneficial targets enshrined in law but also some of the more ill conceived ones. Back in June in a speech to the NHS confederation Andy Burnham said that:

“Now we have a chance to…move away from the focus on numbers and systems. We need to deep-clean the target regime. Where they are subsidiary to wider objectives they should be removed…Where targets are important and about end-to-end service standards [they should be kept].”

At the time I and many of my colleagues welcomed Burnham’s statements, hoping that they would lead to a serious reappraisal of many of the targets that infest our system including the 4 hour A&E wait, which is in many ways the perfect example of how targets can damage patients. The sad truth of the matter is that when on call for a speciality you learn very quickly that the first question that you should ask a doctor referring a patient from A&E is not what their blood pressure or pulse is, it’s not if they are haemodynamically stable or if they are in respiratory difficulty, it is in fact when do they breach? As in when do they breach the four hour A&E target. This sadly becomes the most important question to ask.

The reason for this is that in A&E patients are often provisionally marked up as destined for a certain speciality as soon as they come through the door (eg chest pain marked as cardiology); the problem is that this is done before a doctor will even get to examine the patient. What tends to happen is that you will get paged by A&E asking you to admit a patient under your speciality. Now, if it’s a good referral or someone that you can trust then it’s easy to accept the patient over the phone but in practice, as in any other sector, there are poor doctors. Even good doctors are often pressurised by the management in A&E into trying to “punt” patients from the department even to inappropriate specialities in order to avoid them breaching.

As a result as an admissions doctor you must prioritise based on who you see – not on who needs your care most, but who will breach the government targets first. And if you don’t assess them yourself before they breach they will end up under your care and speciality anyway.

This is extremely detrimental to a patient’s care. It can often result in them ending up on inappropriate wards where neither the medical nor nursing staff have the expertise they need and the wards themselves lack the equipment to optimise care. The net result is that some patients can languish on wards for days while they wait to be transferred to the appropriate speciality or even worse they are inappropriately diagnosed and discharged (I have seen this happen). This is all so that we can have the much vaunted 4 hour wait which while benefiting those with minor injuries can cause severe problems for those with serious and possibly life-threatening conditions.

It has also led to the development of “medical assessment units” – in many cases not much more than glorified waiting rooms so that patients can be marked off as “out of A&E”. In the most extreme of circumstances patients are just put in a trolley and left in a corridor as this also counts as “out of A&E”.

Most A&E consultants I have spoken to and also 90% in surveys support the idea of the 4 hour A&E wait but not its implementation. Many feel that it is in fact the rigid implementation that leads to a decline in patient care. In fact in the last BMA survey only 56% of respondents felt that the government’s targets were achievable.

The point I am trying to make is that while targets can be good for the NHS they can also be extremely bad for both the service and patient care if misapplied. I am left agreeing with Katherine Murphy the Director of the Patients Association who recently said:

“Targets are still perverting care in too many cases. Elderly patients admitted through A&E don’t tick any of the target boxes when they’re admitted to wards. It’s no surprise they can end up being neglected.Until this problem is addressed targets can still have a detrimental effect on patient care. Fixing this problem should be the priority-not coming up with vote winning initiatives.”

If we truly want to maintain our position as “the party of the NHS” then we have to put its interests and the interests of the patients above our own political goals. Reform of the system rather than enshrining our targets in law should be the priority. It’s very often the rigidity of the targets that is the problem and making them law will only reinforce this. I hope that Andy Burnham takes heed because this is far more important than electioneering.